Two separate reports sound alarm on PBM practices that harm patients, consumers

The three largest drug middlemen — CVS Caremark, OptumRx and Express Scripts — together control more than 95% of prescriptions filled in the United States every year (Getty Images).

Consumers should be alarmed by two independent reports that accuse pharmacy benefit managers, the influential middlemen in our health care system, of deploying anticompetitive pricing tactics that jeopardize patient care and undermine local pharmacies.

The reports by the Federal Trade Commission and U.S. House Committee on Oversight and Accountability echoed concerns long voiced by consumers, doctors, pharmacists and other advocates that pharmacy benefit managers, or PBMs, have too much power and influence over patients’ access to medicines and the prices they pay. They also appear to agree this power-grab didn’t happen by accident.

PBMs have consolidated the delivery of medicines by merging with or acquiring other entities within the supply chain, allowing them to serve as health plans and pharmacists, among other roles. Both reports concluded that a lack of transparency and accountability mechanisms within the pharmacy supply chain have allowed bad actors to pocket rebates and deep discounts intended to reduce the cost of medicines for patients.

The FTC’s report found the six largest PBMs control 95% of prescriptions filled in the United States every year. Described as an “interim” report, the July 9 document said PBMs drive up the costs for many lifesaving drugs, including cancer drugs and squeeze independent pharmacies out of the market, making it more difficult for some residents in rural and underserved communities to get medicines locally.

Two weeks later, the House Committee on Oversight and Accountability issued a report on its own investigation that found evidence of PBMs inflating prescription drug costs and interfering with patient care for their own financial benefit. It focused on the three largest PBMs — CVS Caremark, OptumRx and Express Scripts.

House Oversight Committee Chairman James Comer, a Republican from Kentucky, didn’t mince words when releasing the report: “These self-benefitting pricing practices pushed by the PBMs have done nothing but jeopardize patient care, undermine local pharmacies and raise prescription drug prices.”

Both reports found that PBMs hold substantial influence over independent pharmacies by imposing unfair, arbitrary and harmful contractual terms that can impact their ability to stay in business and serve their communities. This is especially concerning for rural communities, where the local pharmacy is often the only pharmacy option for citizens, who depend on it to get everything from a flu shot to lifesaving medicine.

It was also clear from both reports that PBMs hold substantial power over patients’ ability to access and afford their prescription drugs. They noted that PBMs frequently tout the savings they provide payers and patients through negotiations, drug utilization programs and other pricing mechanisms, even though the evidence indicates they often increase costs for patients and taxpayers.

Ultimately, if the rebate system functioned as it should, and as consumers are led to expect, patients would notice a reduced price for their medicine when paying at the pharmacy.

These discounts could mean the difference between patients getting a pricier advanced prescription that improves their health or not being able to afford a medication, skipping doses, or opting out of the care plan altogether. Given all of the advanced treatments and medications our healthcare system has to offer, it’s unacceptable that patients may have to skip a prescription because a discount wasn’t passed along to them.

The Oversight Committee report urged Congress and states to implement legislative reforms to increase transparency. Meanwhile, the FTC said it remains committed to providing timely updates as the Commission receives and reviews additional information.

While both are encouraging, it should be abundantly clear to everyone that PBMs’ present role is failing patients and consumers. Increased transparency and accountability are needed.

The FTC and the Oversight Committee must continue to maintain a watchful eye over PBMs and act accordingly to ensure patients and consumers are able to affordably access the medicines they need where they live.